Santoyo, Gabriela

Applicant Gabriela Santoyo injured her lumbar spine after a slip-and-fall at work and her treating physician, Dr. Nussbaum, requested microdiscectomy surgery at L5-S1 via a May 10, 2023 RFA. Defendant's May 18, 2023 UR denial was found untimely by the WCJ, shifting the issue to whether the surgery was reasonable and necessary, which the WCJ found it was not. On reconsideration, the Appeals Board majority granted the petition and reversed, finding that the medical record—particularly Dr. Nussbaum's reporting predicated on reasonable medical probability—established the surgery met MTUS-ACOEM guidelines criteria. The Board emphasized that contact with the S1 nerve root, radicular pain syndrome, and continued functional limitation beyond six weeks of conservative care satisfied the guidelines, which allow physician clinical discretion. Commissioner Razo dissented, agreeing with the WCJ that applicant failed to satisfy all three MTUS prongs, particularly the imaging requirement of nerve root compression. The Board granted the surgery request.